Provider Demographics
NPI:1043266174
Name:MUSHTAQ, MIAN (MD)
Entity Type:Individual
Prefix:
First Name:MIAN
Middle Name:
Last Name:MUSHTAQ
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:315 E BROADWAY
Mailing Address - Street 2:
Mailing Address - City:LOUISVILLE
Mailing Address - State:KY
Mailing Address - Zip Code:40202-3700
Mailing Address - Country:US
Mailing Address - Phone:502-629-2500
Mailing Address - Fax:502-629-2055
Practice Address - Street 1:301 GORDON GUTMANN BLVD
Practice Address - Street 2:STE 301
Practice Address - City:JEFFERSONVILLE
Practice Address - State:IN
Practice Address - Zip Code:47130-3764
Practice Address - Country:US
Practice Address - Phone:812-288-9969
Practice Address - Fax:812-288-9657
Is Sole Proprietor?:No
Enumeration Date:2006-05-26
Last Update Date:2021-01-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN01047786A207RH0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RH0003XAllopathic & Osteopathic PhysiciansInternal MedicineHematology & Oncology
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN200437800Medicaid
KY64053093Medicaid
IN200437800Medicaid
INM400062886Medicare PIN
IN200437800DMedicaid
KY64053093Medicaid
KYG86624Medicare UPIN
IN200437800FMedicaid
IN196240JMedicare PIN
IN200437800AMedicaid
IN243690MMedicare PIN